Behavioral Health Providers: Facility/Ancillary Application Addendum

Transcription

1 Please complete a separate form for each clinical location. Provider identification Legal business name: Doing business as (if applicable): Address: Anthem Blue Cross and Blue Shield Healthcare Solutions Behavioral Health Providers: Facility/Ancillary Application Addendum City: State: ZIP: Contact person: address: Phone: Tax ID: NPI: Facility services Please check all facility-based services you are licensed to provide. Facility service type 23-hour observation Ambulatory detox services Crisis stabilization unit Eating disorder inpatient acute hospital Eating disorder inpatient rehabilitation Eating disorder residential treatment center Inpatient detoxification Psychiatric inpatient acute hospital Psychiatric inpatient rehabilitation Psychiatric residential treatment center Substance abuse detox Substance abuse inpatient rehabilitation Substance abuse residential treatment center Anthem Blue Cross and Blue Shield Healthcare Solutions is the trade name of Community Care Health Plan of Nevada, Inc., an independent licensee of the Blue Cross and Blue Shield Association. ANTHEM is a registered trademark of Anthem Insurance Companies, Inc. ANVPEC December 2017

2 Page 2 of 6 Outpatient/professional services Please check all outpatient services for which you are licensed and have at least two years of clinical experience in the area of expertise. This behavioral health application addendum is designed to be used for all health plans. Please use the service definitions that are applicable to your state Medicaid plan. While not all services listed are covered benefits in your state, having complete information on what our providers offer will be valuable should changes occur. Outpatient service types/areas of expertise AIDS/HIV issues ADD and ADHD Agency services Applied behavioral analysis Art therapy Assertive community treatment (ACT) Assessment services (CANS and ANSA) Autism spectrum disorder program/services Behavioral health care coordination Case conference Case management services level I Case management services level II Community mental health center services Community integration counseling Community residences (licensed) Community psychiatric support treatment (CPST) Community transitional services Co-occurring (MH/SUD) diagnosis Coordinated system of care (CSoC) Court-ordered services mental Court-ordered services substance use disorder (SUD) Crisis intervention services Day treatment mental health Day treatment SUD Developmental disabilities Dual diagnosis (IDD + mental illness) crisis respite Dual diagnosis (mental illness + SUD) crisis respite

3 Page 3 of 6 Outpatient service types/areas of expertise Eating disorders Electro-convulsive therapy Family support services Family therapy MH Family therapy SUD Functional family therapy (FFT) Foster care Group therapy MH Group therapy SUD Halfway house Health home services Homebuilders Illness management and recovery services Inpatient physician (MD) services Intellectual development disabilities Integrated care behavioral health/medical Intensive outpatient program eating disorders

4 Page 4 of 6 Outpatient services types/areas of expertise Intensive outpatient program mental health Intensive outpatient program SUD Justice system services Learning disabilities Mental health skill building Methadone opioid treatment Mobile crisis services Mood disorders Multidimensional family therapy (MDFT) Multisystemic therapy (MST) Neuropsychological testing Outpatient substance abuse Partial hospitalization program eating disorder Partial hospitalization program mental health Partial hospitalization program SUD Peer support services mental health Peer support services substance use disorder Permanent housing Play therapy Pregnant female MH/SUD services Pregnant female medication assisted Program for Assertive Community Treatment (P-ACT) Psychiatric medication management Psychiatric outpatient Psychological testing Psychosocial rehabilitation services Respite services Respite services crisis Social detox Supported employment

5 Page 5 of 6 Outpatient services types/areas of expertise Supportive housing enhanced Supportive housing mental health Supportive housing substance use disorder Telepsychiatry Teletherapy Therapeutic child day care Therapeutic group home Therapeutic group home substance abuse Therapy services mental health Therapy services substance use disorder Transitional housing/living (18-20 years old) Transitional housing for pregnant members Transitional housing for mothers with children Trauma services Veterans services Vocational rehabilitation Youth support All: Please check all applicable areas/services/specialty that apply to your professional services. Psychiatrist (adult) Psychiatrist (child) Psychologist (adult) Psychologist (child) Psychologist Psychologist Medical psychologist Psychologist school counseling developmental Licensed clinical social Licensed professional Licensed marriage and Suboxone (MD) worker counselor family therapy Psychiatric Psychological examiner Licensed certified Certified subutex NP/APN/CNS (SPE or PE) alcohol/drug counselor

6 Page 6 of 6 Provider areas of expertise: To keep our online provider directories up to date, it is important for us to know your areas of expertise. This information helps our clinicians when directing referrals and assisting members who access care directly. Please check all areas that apply to your practice. ADD/ADHD Addiction disorders child issues Adoption attachment issues Aging services AIDS/HIV issues Ambulatory detox Anger management Anxiety panic disorders Art therapy Autism spectrum disorders Behavioral analysis Behavioral therapy Chemical dependency assess development welfare protection (CSOC) Co-occurring (MH/SUD) Dx Coordinated system of care Dialectical behavior therapy Divorce custody issues Domestic violence Dual diagnosis (MI/DD) Eating disorders Electroconvulsive therapy Engagement services Expert witness testimony Family therapy First episode psychosis Gender identity concerns Grief loss separation Inpatient physician, MD Integrated BH/medical services Hearing impaired Learning disabilities Lesbian/gay/bisexual/transgender Medical psychologist Medication management Motivational interviewing Methadone maintenance Mood disorders Pain management Music therapy Obsessive compulsive disorder Peer support services veteran Peer support services MH Peer support services (SUD) Play therapy Personality disorder Pharmacy psychiatric Psychological testing Postpartum depression issues Pregnant female MH/SUD Recovery skills Psychosis schizophrenia Rational emotive BH trt. (REBT) Sexual issues disorders Severe emotional disturbance Severe mental illness Sexual physical abuse child Sexual offender program Sexual physical abuse adult Substance use/abuse Stress management Suboxone program Telepsychiatry Subutex program Supported employment Trauma behavioral therapy Teletherapy Transition age youth Violence prevention Traumatic brain injury Veteran issues Violent offender services